2.0 Analysis 2.1 Introduction It is essential that moving parts in service that can constitute a safety hazard for users be kept in good working condition, inspected on a regular basis, and properly maintained. 2.2 Lifeboat Inspection ChapterI, PartB, Regulation8(a) of the SOLAS Convention requires that surveys of life-saving appliances and other equipment on cargo ships be conducted every 24 months. These inspections are to be carried out by government officials of the country of registry or by designated inspectors or organizations recognized by that country. In October 1992, as the inspection for the issuance of a Cargo Ship Safety Equipment Certificate required that the lifeboats be tested, the Lloyd's representative indicated on his checklist (at item G.1) that the two lifeboats had been lowered to the level of the boat deck. The Lloyd's representative nonetheless indicated on the same checklist (at item G.11) that he considered that the forward and after fall blocks on the two lifeboats, which are integral parts of the launching appliances, needed to be replaced because of their corroded condition. However, he did not note any defect of the connections on the starboard lifeboat. It was determined that the forward connection was as much as 88 to 89percent deteriorated, and the after connection was deteriorated as much as 90 to 94percent. Such a considerable deterioration only could have developed over a period of several years. In addition, a post-occurrence examination of the connections revealed that the fractures were not fresh over their full width. In view of the foregoing and of the fact that the Port State Control Inspection at Montreal revealed some 54 regulation violations or safety deficiencies, there is some doubt that there was sufficient attention to detail in the classification society survey. The Port State Control Inspection led to a detention order being issued against the IRAN SALAM. As the shortcomings were not referenced in the annex to the short-term certificate issued to the vessel in October 1992, and only the fall blocks and limit switches were mentioned, this seems to indicate that all sheaves, blocks, lifting hooks, hook foundations and securing arrangements, and all moving parts had been inspected and found in good condition. However, subsequent events indicate otherwise. Sometimes, a different marine surveyor may have to do the follow-up on shortcomings noted in the annex to a certificate. When this happens, if the shortcomings are not cross-referenced with specific items on the checklist, the surveyor doing the follow-up might check only those items noted on the short-term certificate, thereby inadvertently compromising safety. A commissioned officer on the vessel inspected the lifeboats on a monthly basis. The findings of these inspections were recorded on a ship's checklist. The checklist does not indicate the condition of the lifting hooks or the connections between the lifting hooks and their metal base plates attached to the keelson. The connections were not visible, but they could be accessed through trap doors in chests located at either end of the starboard lifeboat. There is some doubt that there was sufficient attention to detail during the inspections carried out by the vessel's officers. The ship's log indicates that the starboard lifeboat was launched during a drill on 21October 1993. The entry reads: At 1000hrs. stb. lifeboat prepared and lowered to water level. All moving parts checked and greased; also limit switches tested and found in good working condition. 2.3 Analysis of the Connections An analysis of the connections of the lifting hooks by the TSB Engineering Laboratory could not determine with accuracy the maximum weight that the connections could support at the time of the accident. However, the analysis of the sequence of events confirms that the after lifting hook connection was capable of supporting only a light load because of its advanced state of corrosion, which greatly exceeded safety standards. 2.4 Lifeboat Gripes The method used to rig the lifeboat gripes on the IRAN SALAM was incorrect for this type of installation. It is common practice to fit turnbuckles to the lower ends of the gripes so that they can be released from the boat deck without boarding the lifeboat. The turnbuckles of the lifeboats on the IRAN SALAM were at the upper ends of the gripes; therefore, crew members had to climb aboard the lifeboat to release them. However, there are no rules requiring that the turnbuckles be fitted to the lower ends of the gripes rather than to the upper ends. 2.5 Conduct of the Inspection CCG Ship Safety Branch inspectors were carrying out a Port State Control Inspection aboard the IRAN SALAM. As lifeboat launching appliances are included in the safety equipment control program, they were tested. After the port lifeboat was tested, the inspector in charge requested that the starboard lifeboat be released from its stowage, and the lifeboat crashed on to the wharf. Subsequently, CCG inspectors decided to carry out a full survey of the vessel, and they noted some 54 shortcomings on the IRAN SALAM. 3.0 Conclusions 3.1 Findings A Cargo Ship Safety Equipment Certificate was issued to the IRAN SALAM by the Lloyd's classification society in London, United Kingdom, in May 1993, six months before the accident. A Port State Control Inspection carried out on 18December 1993 in Montreal revealed some 54 shortcomings relating to safety equipment aboard the IRAN SALAM. Crew members had to board the lifeboat in order to release the securing gripes. The connections in way of the lifting hook base plates at the forward and after ends of the lifeboat were in an advanced state of corrosion. The connections could be accessed through trap doors in chests located at either end of the lifeboat. An examination of the connections carried out by the TSB Engineering Laboratory revealed that the fractures were not fresh over their full width. An accumulation of water in the bilges could have contributed to the corrosion of the metal parts. The two crew members who had boarded the starboard lifeboat had to undergo major surgery and they were hospitalized for several weeks. 3.2 Causes The lifeboat connections in way of the lifting hook base plates were corroded by rust and failed under the weight of the lifeboat when the gripes were removed. Lack of attention to detail during the inspection for the issuance of a Cargo Ship Safety Equipment Certificate contributed to the accident. 4.0 Safety Action 4.1 Action Taken 4.1.1 Inspections Deficiencies noted on the vessel during the Port State Control Inspection were corrected before the vessel departed Canadian waters. Following this occurrence, the classification society (Lloyd's Register of Shipping) issued an internal policy calling for increased attention, during lifeboat inspections by its surveyors, to the moving parts of lifeboat launching gears, such as lifting hooks and base plates.